February 12, 2018
Since President Trump was inaugurated 13 months ago, no one has been expecting his administration to champion nutritious food, especially in comparison to the Obama administration, which was more active than any other with respect to policies to encourage healthful eating and reduce diet-related disease. (The Obama years were marked by the Let’s Move campaign, the passage of the Healthy, Hunger-Free Kids Act, mandatory menu-labeling as part of the Affordable Care Act, and a pretty substantial overhaul of the Nutrition Facts label on food packaging.)
So far, there have been no major reversals of Obama-era nutrition policy in the Republican president’s term. In fact, FDA issued draft guidance for industry to implement menu-labeling regulations that for the most part stayed true to the letter and spirit of the law.
But it’s obvious that the Trump administration until recently has shown little interest in food as a means to improve public health. Since the inauguration, FDA has delayed the enforcement dates for both restaurant menu labeling and the Nutrition Facts panel update, ostensibly to ease the regulatory burden on the food industry. In October of last year, a White House memo leaked to the press indicated just how low of priority diet-related disease is to the president and his staff. The memo characterized the prior administration’s attention to obesity as “inexplicable” and indicated a desire to shift CDC funding away from nutritional efforts to prevent disease. In late November, USDA issued an interim final rule to weaken some of the evidence-based school lunch requirements that were mandated by the Healthy, Hunger-Free Kids Act of 2010. The changes were relatively small, but they worried school nutrition advocates that further regressions of the rules would follow.
Recent events would indicate that the tide might be turning, however. In November, FDA Commissioner Scott Gottlieb told Politico somewhat cryptically that his agency would be pursuing a “broader policy initiative” using “nutritional information as a way to prevent disease and death.” Last month FDA released a policy “roadmap” outlining just what Commissioner Gottlieb was referring to in his comment. Among four primary strategies identified in the document is one specifically focused on promoting informed food choices, highlighting the important role of nutrition in disease prevention. The associated “Nutrition Action Plan” (click to enlarge the image ) includes education for consumers and guidance for industry around menu-labeling and the Nutrition Facts update. Additionally, FDA proposes considering a number of new policy options in the nutrition arena. Just this week, FDA announced it is allocating $3 million for the Nutrition Facts educational campaign.
So what’s going on here? Why, all of a sudden, is the administration looking to be so progressive on nutrition? Is FDA not communicating with the White House? Such a degree of disorganization would not be atypical of the administration we have come to know. On the other hand, I would argue that these proposals are not as enlightened as they sound.
What stands out about the majority of these action items is that they take an informational approach, which puts the burden on consumers to make more healthful decisions. There’s nothing wrong with that approach per se, but information only goes so far in actually changing what people eat on a regular basis.
Obama administration officials Joanne Guthrie, Lisa Mancino, and Chug-Tung Jordan Lin published an article on this topic in 2015 in the journal Psychology and Marketing, asserting that although there are certain advantages to an educational approach to dietary change—after all, many of the Obama-era nutrition initiatives were information-based—there is no solid evidence that nutrition labeling improves food choice, diet quality or health outcomes. Applying nutrition information to food choices is difficult and time-consuming, and may only be relevant for a small subset of highly motivated and knowledgeable consumers. Government approved health claims featured on food packages that address one nutrient can even mislead consumers to infer incorrectly the overall healthfulness of the product. Furthermore, according to the authors, there are a myriad of factors that consumers take into account when making food choices. Often short-term reward takes priority over long-term health outcomes that are not easily attributable to habitual food decisions. Taking a systems view, I would add that there are many additional factors that determine what choices are even accessible to a consumer, which in some cases make nutrition knowledge less relevant. A 2013 study of food desert inhabitants found that external constraints prevented participants from purchasing products they considered healthy despite their substantial nutrition knowledge.
All of this is not to say that government should not ensure that nutrition information is provided. But if information provision is not sufficient to improve public health, then other approaches should be pursued, taking into account the physical, social, economic and policy environment in which food choices are made. In terms of the physical food environment, one example offered by Guthrie, Mancino and Lin is that presenting a healthier option as the default—e.g., water instead of soda in a fast food meal—will increase the likelihood of consumers choosing that option. Schools, universities, corporations and government employers routinely serve meals to many Americans; improving the healthfulness of their offerings could shift consumer choices at a meaningful scale. To address socioeconomic disparities in food access, financially incentivizing SNAP recipients to purchase more fruits and vegetables has proven incredibly promising. Sam Kass, former nutrition policy adviser to President Obama, has pointed out that investment is desperately needed for research to grow fruits and vegetables more efficiently and resiliently so that the costs can compete with less nutrient dense foods. Given that poor diets disproportionately affect people of color and low income, it is likely that sustainable improvements in nutritional wellbeing will require policies to relieve disparities and promote equity broadly.
The bottom line is that if FDA is trying to pass off this “roadmap” as a genuine commitment to preventing disease via nutrition, the agency is, for the most part*, pursuing the low-hanging fruit and not targeting the most important levers for dietary change. I applaud FDA’s attention to nutrition, but I’m not convinced these proposals will make a dent in diet-related disease. Public health advocates should continue to hold federal officials accountable to pursue evidenced-based strategies to improve the food system.
* I say “for the most part” because of the proposal to advance “guidance on dietary sodium reduction,” which refers to the Obama-era initiative to issue voluntary guidelines for manufacturers to reduce the salt content of food products. These guidelines, if acted upon—and that’s a big IF—would improve the set of choices available to consumers. This leads me back to my initial hunch that all of this is a result of miscommunication in the executive branch, because delaying the progressive reduction of sodium was one of the ways USDA proposed to weaken school lunch requirements earlier in President Trump’s term. In any case, click here to put in your two cents on FDA’s draft sodium reduction goals.